Big city nights are not what lures 60-year-old Sonam Tshering to Bangkok regularly. He is a patient at the Thai capital's Bumrungrad Hospital where he checks-in for his annual check-up. "Here in Nepal it's difficult to even make an appointment with a doctor, and when I do, I get shoddy treatment. I wont' accept anything mediocre when it comes to my health," says the businessman. And although he knows Nepal has many good doctors, Sonam distrusts the calibre of Nepal's medical facilities.

Sonam's lack of faith in Nepal's medical system is neither new nor unique. For decades, Nepalis with even simple medical conditions have gone abroad for treatment. It used to be the missionary hospitals across the border in Bihar, or in Vellore in the south, or AIIMS in New Delhi. Lately, it is Thailand's unique brand of 'medical tourism'. Fed with horror stories of misdiagnosis and malpractice back home, the exodus of patients abroad has slowed but not abated.

But things are changing. There are even indications that Indians are coming to Nepal for treatment in Nepali facilities: especially for eye problems, heart or cancer. As the quality of Nepali hospitals grow, and specialist doctors return to Nepal from abroad, Nepalis are finding that a lot of the operations that used to require medical evacuation to India or Thailand can now be done locally. Although medical treatment in Nepal is not cheap, it is still less expensive than roundtrip air tickets and a lengthy stay at hospitals in New Delhi or Bangkok.

At A&M Marketing, Amod Pyakuryal represents Bangkok's Bumrungrad Hospital in Kathmandu, and says it offers world class care for costs that are "not much higher" than Delhi or Bombay. A standard coronary artery by-pass with an eight night stay at Bumrungrad costs $5,763. Bumrungrad gets 200,000 international patients a year, and there has been criticism in the past that it is too big to give individualised care. Still, approximately 500 referrals were made from Nepal last year for everything from gastro-enteritis to cardiac surgery.

Procedurally, a doctor makes a medical referral after consulting the patient and family, and concluding the required facility or procedure is not available in Nepal. Sometimes things don't even get that far. Buddha Basnyat, medical director at The Nepal International Clinic, which treats mainly expats, says: "There are two things patients consider: whether they get a definitive diagnosis and the treatment prescribed. But reliability of lab testing in Kathmandu often poses a limiting factor. Without proper diagnosis, treatment becomes difficult."

While the trend of medical referrals abroad by doctors is now limited to special cases, the good news is there has also been a recent decline in Nepalis going abroad for treatment. Nepal now has exceptional doctors and facilities, especially in cardiology, neurology and opthalmology. Cardiac care has improved significantly both in the public and private spheres.

At Shahid Gangalal National Heart Centre, executive director Bhagawan Koirala (pic top, at the operating table) has provided quality care for the past two years, and recently, the government hospital began charging subsidised rates. "We've made cardiac care accessible, so Nepalis don't have to go to India or Thailand for treatment anymore," says Koirala. The hospital in Bansbari already sees 25,000 cardiac patients come through every year, and many of them get subsidised care. But Koirala is open to referring patients to facilities abroad if they are high-risk cases, or if the family prefers.

Since the private educational facility opened in 1994, Suresh Ramachandran, medical superintendent at Manipal, estimates the number of patients going to India has decreased by 20 percent, especially with concessions for poor patients. Up to 40 percent, depending on the case, are given free beds and fulltime residential doctors regularly waive fees. Ramachandran told us, "As a teaching hospital, Manipal's already very competent staff will only improve as post graduate students stay to develop more departments and our South Indian nurses are replaced with Nepali nurses trained here."

Manipal has modern laboratories with a total analyser. It can run 100-150 tests automatically from a small sample of blood. The lab also produces accurate investigations of thyroid hormone levels, goitres, HIV through the Western Blot test, cervical cancer using Pap Smears, skin biopsies to detect leprosy, all of which meet international standards.

The lack of proper facilities is the only justifiable reason for referrals according to Bharat Rawat, Executive Director at Norvic in Kathmandu. But he admits it is an uphill battle to convince patients they can trust local treatment. He refers less than five percent of his cases, and only those that entail risky procedures. Other than updating facilities and skills, Rawat believes Nepal's medical profession could do with a communication skills makeover: "Talk to patients, give them respect, let them call you on your phone and don't hide the truth from them." He has noted a turn in the tide of Nepali heart patients going abroad and estimates it's down to 25 percent from 80 percent three years ago. "I try and convince Nepalis that we can provide services that are as good, if not better, than some hospitals abroad. The next step is to convince insurance companies that travellers and expats living in Nepal can get quality care at cheaper rates, avoiding the risk of transportation," says Rawat. "Someday, I'd even like to see foreigners considering Nepal as a medical destination."

That may take some time, but oncologist Sudip Shrestha at the Bhaktapur Cancer Care Centre says, "We must improve the diagnostic capabilities of facilities in Nepal, which is the major reason for referrals abroad."